**2. Advantages and limitations of regional anesthesia**

The practical advantages of regional anesthesia are faster postoperative recovery, better postoperative analgesia, avoidance of opioid-related side effects, and prevention of GA-related complications in patients with cardiovascular and respiratory comorbidities, e.g., sleep apnea, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), etc. The perioperative patient satisfaction and hospital efficiency are readily perceptible with the use of these regional anesthesia techniques albeit the sparsity of data on long-term outcome following surgery. On the other hand, the availability of sophisticated equipment, specialized operator training, requirement of a dedicated block room, and protected block execution time are some of the limitations with routine practice of regional anesthetic techniques. Though the use of ultrasound as a nerve localization tool has shortened the learning curve and boosted operator comfort level with peripheral nerve blocks, it does not the eliminate the procedure-related complications.

limb can be localized using nerve stimulation or ultrasound. It is also devoid of complications like pneumothorax and hemi diaphragmatic paresis. The block performance time with axillary block is relatively longer than with the supraclavicular and infraclavicular blocks due to the higher needling time [4, 5]. Also multiple injection technique has higher success rate than single or double injection technique when a non-ultrasound-guided technique was used [6].

Regional Anesthesia for Hand Surgeries http://dx.doi.org/10.5772/intechopen.76786 9

The patients' arm is abducted with elbow flexed and supported in this position to expose the axilla (**Figure 1a**). A high-frequency linear array transducer is used to obtain a cross-sectional view of the axillary artery just distal to the anterior axillary fold (**Figure 1b**). At this point the radial nerve is still in close proximity to the axillary artery above the conjoint tendon formed by the teres major and latissimus dorsi (**Figure 1c**). Distal to this level, the radial nerve exits posteriorly through the triangular space and is difficult to visualize(**Figure 1d** and **e**). The median nerve is often lateral or superior to the axillary artery, and the ulnar nerve lies medial or posterior to the artery. The musculocutaneous nerve usually exits brachial plexus earlier and is found lateral to the artery between the heads of coracobrachialis muscle or between biceps and coracobrachialis. Variations in the relations of these nerves can be very commonly

After obtaining the image as shown in **Figure 1c**, the block needle can be inserted in plane with or without the nerve stimulation. The musculocutaneous nerve can be blocked first as it is located lateral to the artery and often encountered first while entering in plane. The nerves need to be surrounded by local anesthetic for the block to take effect satisfactorily. The radial, medial, and ulnar nerves can be subsequently blocked by redirecting the needle. The block can be performed

Infraclavicular block is a brachial plexus block performed at the levels of the three cords of the brachial plexus which are arranged around the subclavian artery. The cords are named lateral, medial, and posterior cords based on their fairly consistent relation to the axillary artery (**Figure 2e**) [8]. With the exception of a few nerves that depart the brachial plexus at the level of roots and trunks, the cords comprise of most of the sensory and motor innervation of the upper extremity. Hence, this block is an excellent anesthetic technique for surgeries of the distal arm, forearm, elbow, and hand. This block is relatively easier to perform with the ultrasound as the neurovascular bundle is deeper making it difficult to perform with nerve stimulation technique. Though the risk of hemi diaphragmatic paralysis is very rare, the risk of pneumo-

with one needle entry occasionally requiring a second pass to target one of the nerves.

thorax is still present if the needle is directed blindly medially toward the pleura.

For this block the patients' arm needs not be abducted, but abduction may help with visualization of the neurovascular bundle by stretching the overlying muscles and also potentially displacing the neurovascular bundle away from the chest wall. Though a high-frequency linear array transducer often should suffice for this block, in obese or muscular patients, a low frequency curvilinear transducer may be required. The probe is placed in a parasagittal plane

seen, but the nerves can be identified by tracing their course distally [7].

*3.1.1.1. Technique*

*3.1.2. Infraclavicular block*

*3.1.2.1. The technique*
